Failure to Notify Physician and Resident Representatives of Significant Changes and Missed Medications
Penalty
Summary
The facility failed to ensure timely and appropriate notification of physicians and resident representatives in accordance with facility policy for multiple residents. For one resident admitted with complex medical needs including leg surgery, chronic kidney disease, and hypertension, several prescribed medications were not available and thus not administered as ordered. Nursing staff did not notify the physician or APRN about the missed doses, nor did they document such notifications, despite facility policy requiring immediate action and provider notification when medications are unavailable. Interviews confirmed that the responsible nurses did not follow the required procedures for reordering medications or for notifying the provider and documenting the event. Another resident, admitted with a history of falls and dementia, developed a new pressure ulcer that was first identified during a weekly skin check. The wound was not assessed by an RN, and neither the APRN nor the resident representative was notified until nine days after the initial finding. During this period, no treatment was initiated for the pressure ulcer, and the dietitian was not informed in a timely manner, delaying nutritional interventions that could support wound healing. Staff interviews revealed a lack of understanding or adherence to the protocol for new wound identification, assessment, and notification. A third resident with diabetes experienced multiple episodes of hypo- and hyperglycemia, some requiring emergency interventions such as IM Glucagon or glucose gel. Despite physician orders and facility protocols requiring provider and resident representative notification for blood glucose levels outside specified parameters, there was no documentation of such notifications for numerous incidents. Nursing staff often failed to document the events or communicate them to the appropriate parties, and in some cases, did not administer insulin as ordered or notify the provider when doses were held. Interviews with staff indicated confusion about roles and responsibilities regarding assessment, documentation, and notification in these situations.